Prognostic predictors for mortality of patients with COVID-19 in an intensive care unit.

INTRODUCTION: Fatality due to COVID-19 continues to be a challenge. Timely identification of critical COVID-19 patients is crucial for their close clinical follow-up and treatment. We aimed to identify the mortality predictors of critical COVID-19 patients. METHODOLOGY: We analyzed medical records of 232 out of 300 patients with COVID-19 hospitalized in the intensive care unit (ICU) whose medical records were available in the hospital database. Non-survivors and survivors were compared for parameters. Medical records of demographics, comorbidities, radiological signs, respiratory support, and laboratory tests on the first day of ICU admission were included. The durations of ICU stay and hospitalization were also evaluated. RESULTS: The patients with Acute Physiology and Chronic Health Evaluation II (APACHE-II) score above 28.5 and the patients with blood urea nitrogen (BUN) above 45.5 mg/dL were significantly more mortal (95% CI: 0.701, p = 0.0001; 95% CI: 0.599, p = 0.022; respectively). Partial oxygen pressure/fraction of inspired oxygen (P/F) ratio below 110.5 mmHg was a predictor for mortality (95% CI: 0.397, p = 0.018). Older age, smoking, crazy paving pattern on computed tomography (CT), and short duration of hospitalization were also predictors of mortality. The patients requiring invasive mechanical ventilation were significantly more mortal whereas the patients requiring high flow oxygen and non-invasive ventilation were significantly more likely to survive. CONCLUSIONS: We recommend evaluating APACHE-II score, BUN value, P/F ratio, age, smoking status, radiological signs on CT, length of hospitalization and modality of respiratory support upon ICU admission to identify critical patients with poor prognoses.

Does CPAP treatment lead to gastroesophageal reflux in patients with moderate and severe OSA?

Obstructive sleep apnea (OSA) leads to upper respiratory tract obstruction, causing increased abdominal-gastric pressure and decreased lower esophageal sphincter (LES) pressure and thus gastroesophageal reflux (GER). Continuous positive airway pressure (CPAP) is known to be an effective method for OSA treatment, but its effect on GER is still controversial. There are a very few studies investigating CPAP and GER relationship and performed based on pre- and post-treatment objective parameters of GER in patients with OSA. The study investigated the effect of CPAP treatment in patients with moderate and severe OSA without GER complaints on pre- and post-treatment objective GER parameters. The study included 25 patients with respiratory disturbance indices >15 without reflux symptoms who had undergone polysomnography at sleep laboratory. Age, sex, body mass index (BMI), waist, and neck circumference of the patients were documented. DeMeester score, LES pressure, and polysomnography parameters were evaluated pre- and post-CPAP. The results were statistically evaluated, and p value <0.05 is considered significant. Out of 25 patients, 21 were male (84 %) and mean age was 49.2 ± 8.6 (range 31-66). At the pre-CPAP phase, mean sphincter pressure was 22.2 ± 1.2 (range 8-73), and mean DeMeester score was 18 ± 15.5 (range 0.2-57). At the post-CPAP, mean sphincter pressure was 22.9 ± 1.6 (range 9-95), and mean DeMeester score was 16.3 ± 14.8 (range 0.2-55). No significant difference (p > 0.05) was found comparing pre-CPAP and post-CPAP measurements. Objective criteria show that CPAP treatment does not cause reflux in patients with OSA. Unlike studies reported in the literature, this conclusion has been reached by pre- and post-CPAP assessments.

Relationship of CTLA4 and CD28 polymorphisms with lung involvement, HRCT findings and pulmonary function tests in Turkish patients with ankylosing spondylitis.

BACKGROUND AND AIMS: Ankylosing spondylitis (AS) is a multisystem disorder with ocular, pulmonary, and cardiovascular involvement. The incidence of pulmonary involvement varies from 1 to 52%. Abnormal T-cell function-derived immune responses are involved in AS pathogenesis. Numerous genes such as CTLA4 and CD28 control T-cell functions. In this study, we aimed to address the relationship between CTLA4 and CD28 polymorphisms and lung involvement in Turkish patients with AS. METHODS: A cross-sectional evaluation of 80 healthy and 89 AS subjects with no active infection or malignancy was performed to determine the relationship between pulmonary involvement and CTLA4 and CD28 gene polymorphisms. All patients were assessed for clinical, radiological, and spirometric findings. Descriptive statistics, chi-square tests, and independent-sample t-tests were used for statistical analyses. RESULTS: All patients with the CD28 CC genotype (n = 4) had abnormal HRCT, but it was not significant (p = 0.47). All of the normal HRCT patients have CD 28 T alleles. In addition to this data ; 4 patients who have not any T alleles have abnormal HRCT finding. It was significant and was considered that T genotype have protective effect (p= 0,047) on radiologic involvement but no other association was found between CTLA4 and CD28 gene polymorphism with respect to pulmonary function tests (PFT), diffusion capacity, and clinical characteristics in the Turkish patients with AS. CONCLUSION: Our results suggest a possible association of CTLA4 and CD28 variants with AS pulmonary involvement. Furthermore, these results may lead to the development of new therapeutic agents to control more aggressive forms of the disease. However, further studies are needed in larger populations.

Variables determining the development of colistin-associated renal impairment.

AIM: The aim of this study was to identify the predictors of acute renal injury associated with colistin treatment. METHODS: The patients who received treatment with colistin for more than 3 days were included in this retrospective cohort study. Acute renal injury was defined by the RIFLE (Risk Injury Failure Loss End stage renal disease) criteria. Patients whose serum creatinine levels increased at least 1.5-fold compared with baseline value were considered as cases with renal injury. The independent variables determining the development of acute renal injury were investigated by survival analysis. RESULTS: A total of 112 cases [67 (59.8 %) were male, median age 64 (range: 18-93) years] were included in the study. Acute renal injury occurred in 66 (58.9 %) patients. Renal injury developed in first 7 days of the colistin therapy in 52 (78.8 %) cases and at day 8-23 in 14 (21.2 %) cases. On the day with highest levels of creatinine, 25 (22.3 %), 17 (15.2 %), and 33 (29.5 %) cases were in 'Risk', 'Injury', and 'Failure' group, respectively, according to RIFLE criteria. We identified three independent risk factors predicting acute colistin-induced renal injury: advanced age, low serum albumin levels, and high serum total bilirubin levels [odds ratio (confidence interval) = 1.022 (1.006-1.037), 0.643 (0.415-0.994), and 1.129 (1.014-1.257), respectively]. CONCLUSIONS: The advanced age, low serum albumin levels, and high serum total bilirubin levels are independent risk factors for colistin-induced nephrotoxicity.

Geriatric patients with known acute kidney injury and normal renal function at the time of admittance to the intensive care unit/assessment of RRT requirement and mortality: retrospective case-control study.

BACKGROUND: The objective of our study was to investigate the renal functions on admittance, chronic disease status, the diagnosis on admittance to the intensive care unit (ICU), need for mechanical ventilation and medication groups and their impact over mortality and renal replacement treatment (RRT) requirement in geriatric patients with and without known acute kidney injury (AKI) at the time of admittance. METHODS: A total of 168 patients over 65 years of age having been monitored for more than 24 h in our Respiratory ICU and were assessed retrospectively. Factors influencing the RRT requirement and the mortality rates of patients with known AKI and normal renal function at the time of admittance were reviewed. RESULTS: Of 80 patients, 8 (10 %) without AKI at the time of admittance to the ICU required RRT during the follow-up, however, 72 of those (90 %) completed the follow-up without developing AKI. Of 88 patients, 29 (33 %) with AKI at the time of admittance to the ICU required RRT, however, 59 of those (67 %) completed the follow-up without any need for RRT. CONCLUSIONS: Presence of known AKI in the geriatric population at the time of their admittance to the respiratory ICU remarkably increased both the need for RRT and the mortality with respect to the geriatric population with normal renal functions. After having assessed the reasons justifying RRT and increasing the mortality during the intensive care, gastrointestinal bleeding and hypotension which necessitate the combined use of dopamine and noradrenaline were concluded to be prominent.

The comparative value of pleural fluid adenosine deaminase and neopterin levels in diagnostic utility of pleural tuberculosis.

INTRODUCTION: The aim of the present study was to evaluate and compare the diagnostic accuracy of pleura levels of adenosine deaminase (ADA) and neopterin for the differential diagnosis of pleural tuberculosis (TP). PATIENTS AND METHODS: The study included 50 patients with TB, 27 patients with malignancies, and 24 patients with pleural effusion of non-tuberculous and non-malignant origin as controls. ADA and neopterin levels in pleural fluid were measured by spectrofotometric and ELISA method, respectively. RESULT: Pleural neopterin levels were significantly higher in patients with pleural TB than patients with malignancy (p< 0.001). Pleural ADA levels were significantly higher in patients with pleural TB than patients with malignancy (p< 0.001) and patients with benign non-tuberculosis effusions (p< 0.001). The mean levels of ADA and neopterin in pleural effusion were evaluated according to their underlying diseases for the diagnostic accuracy. As for pleural TB receiving operating characteristic curves identified the following results; The best cut-off value for pleural neopterin was 4.7 U/L and yielded a sensitivity and specificity of 86% and 72.55%, respectively. Taking a cut-off value of 42 U/L for pleural ADA, the sensitivity and the specificity were found to be 88% and 68.63%, respectively. CONCLUSIONS: In the diagnosis of pleural TB pleural neopterin level has a comparable sensitivity to pleural ADA activity. Both markers may find a place as a routine investigation in the coming days for early detection of TB. However, these tests should not be considered an alternative to biopsy and culture.

Use of PET-CT for the assessment of treatment results in patients with sarcoidosis.

BACKGROUND AND AIM: Sarcoidosis is a multisystem disease of unknown origin. Determining the involvement and the response to the treatment is important. The aim of this study was to identify the effects of methylprednisolone and indomethacine on metabolic activity and pulmonary function test parameters in patients with sarcoidosis. MATERIAL AND METHODS: A total of 24 pulmonary sarcoidosis patients were enrolled in the study. All the patients underwent spirometry and [(18)F]fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan before treatment and were divided into two groups according to the necessity of corticosteroid treatment or not. Patients who did not have corticosteroid indication were treated with indomethacine. Symptomatic patients and patients who did not respond to indomethacine treatment received methylprednisolone. Patients were followed up on a monthly basis to determine the response. FDG uptakes as the disease activity were re-evaluated before ending the treatment at the sixth month. RESULTS: Mean age of patients (16 male, 8 female) was 39.79 (9.3) years. Besides mediastinum and pulmonary parenchyma, extrapulmonary sites were also involved in patients with pulmonary sarcoidosis (distant lymph nodes (upper abdominal, supraclavicular, inguinal, and axillary), liver, and spleen). Although maximum standard uptake values of methylprednisolone group regressed significantly (p < 0.001) after treatment, indomethacine group did not have significant regression (p = 0.345). Despite metabolic regressions, spirometry values of patients did not significantly increase (p > 0.005). CONCLUSION: FDG PET-CT may be useful for determining activity and the efficacy of treatments. Methylprednisolone is effective in reducing metabolic activity but does not lead to improvement in functional parameters.

Circadian blood pressure pattern in sarcoidosis patients.

OBJECTIVES: Autonomic dysfunction (AD) is frequent in sarcoidosis and considered a result of small fiber neuropathy. A non-dipper blood pressure (BP) pattern, which is also linked to AD, is associated with increased risk of cardiovascular and renal diseases. The aim of the present study was to evaluate the non-dipping BP pattern in normotensive patients with pulmonary sarcoidosis (PS). METHODS: Sixty-three normotensive patients with PS (group 1) and 49 healthy subjects (group 2) were prospectively enrolled. Ambulatory BP monitoring was performed in all participants over a 24-h period. RESULTS: The non-dipping BP pattern was significantly more frequent in patients with PS compared with the control group (80% vs 53%, respectively, p = 0.002). More advanced PS (grade 2) was an independent predictor of non-dipper BP pattern (odds ratio = 10.4, 95% confidence interval 1.1-95.4, p = 0.03). Masked hypertension and body mass index were also found to be other predictors of non-dipping BP pattern. CONCLUSIONS: The present study showed that non-dipping BP pattern is frequently observed in normotensive patients with PS. The probable mechanism underlying the non-dipping BP in PS is autonomic nervous system dysfunction. PS represents an independent risk factor for non-dipping BP and these patients have increased cardiovascular risk.

Diagnostic value of strain echocardiography, galectin-3, and tenascin-C levels for the identification of patients with pulmonary and cardiac sarcoidosis.

BACKGROUND: Cardiac involvement in sarcoidosis has been associated with poor prognosis. We evaluated myocardial contractility quantitatively in a cohort of pulmonary sarcoidosis (PS) patients with and without cardiac involvement. We also studied markers of fibrosis (tenascin-C [Tn-C] and galectin-3 [Gl-3]) as diagnostic tools for PS and cardiac sarcoidosis (CS). METHODS: Forty ambulatory patients with PS of grades 1-2 and 26 healthy subjects were prospectively enrolled. All patients with PS underwent cardiac magnetic resonance (CMR) to explore the presence of CS. The study population was divided into three groups: controls (n = 26), non-CS patients (n = 34), and CS patients (n = 6). Speckle-tracking strain echocardiography (STE) was performed on all patients, and Gl-3 and Tn-C values were measured in all patients and controls. RESULTS: PS patients had higher levels of Gl-3 and Tn-C than did controls, and the STE parameters of PS patients, including global longitudinal strain (GLS) and global circumferential strain (GCS), were lower than those of controls (p < 0.001 for all comparisons). GLS values were lower in CS patients than in the other groups (p = 0.05). CONCLUSIONS: PS patients demonstrate reduced cardiac contractility, independent of CMR-proven structural cardiac lesions, while patients with structural lesions have a more pronounced drop in strain parameters. Tn-C and Gl-3 are promising markers for the diagnosis of PS, but they are not specific for cardiac involvement.

COPD: an underdiagnosed disease at hospital environment.

BACKGROUND AND AIM: Chronic obstructive pulmonary disease (COPD) is a serious disease with morbidity and mortality due to delayed diagnosis until significant symptoms arise. We aimed to assess the utility of spirometry and COPD Assessment Test (CAT) in detecting undiagnosed COPD patients in a localized area. MATERIAL AND METHODS: People who came to the hospital for patient visit or examination with a smoking history of > 10 pack-years (> 40 years old), and with no known chest disease were invited to study. The participants completed a questionnaire and performed spirometry. Spirometry was performed according to ATS/ERS Task Force on spirometry. COPD was defined as according to the Global Initiative for Chronic Obstructive Lung Disease guidelines. RESULTS: There were 800 subjects screened, and 648, capable of performing spirometry, were included to the study. The mean age was 48.3 ± 9.0 and 38 % of the study population was male. Post-bronchodilator FEV1/FVC ratio was lower than 0.70 in 17 % of the subjects. Median (25-75 percentiles) total CAT scores and among the questions of CAT; cough, phlegm, chest tightness and breathlessness scores for COPD and non-COPD subjects were; 15(9-22) vs 12(6-18) (p = .004), 2(1-3) vs 1(0-2) (p < .001), 2(0-3) vs 1(0-3) (p = .004), 3(1-4) vs 2(0-3) (p > .001), 4(3-5) vs 3(2-4) (p = .001), respectively. Symptom prevalence was as follows: exertional dyspnea 91 %, dyspnea 80.9 %, cough 56.3 % and phlegm 58.3 % in COPD. CONCLUSION: Our study showed that spirometric screening together with the CAT questionnaire may improve the awareness of disease and may determine undiagnosed patients.

Does hormonal control obviate positive airway pressure therapy in acromegaly with sleep-disordered breathing?

INTRODUCTION: Acromegaly is a disease in which uncontrolled release of growth hormone occurs after closure of epiphyseal plates, causing changes in the body that can lead to sleep disordered breathing (SDB). No definite guidelines regarding the treatment of SDB in acromegaly are available. In this study, we aimed to investigate the prevalence of SDB in acromegaly and whether hormonal control alters the necessity of positive airway pressure (PAP) therapy in acromegaly patients with SDB. METHODS: Forty-two acromegaly patients were included in the study and divided into two groups according to disease status, i.e., active or well controlled. All patients underwent polysomnography. Fourteen patients with active acromegaly were diagnosed with SDB and were evaluated for PAP therapy with polysomnography both before and 6 months after disease control was achieved. RESULTS: Sleep-disorder breathing was diagnosed in 22 of 42 patients, 7 of 20 patients with controlled-disease and 15 of 20 patients with active diseases. There were significant reductions in respiratory disturbance index (RDI), apnea index, desaturation index, central apnea number, and rapid eye movement-phase RDI at the control polysomnography. Initially, PAP therapy was indicated in 12 of 14 patients and PAP therapy indication held in 11 patients after acromegaly control was achieved. CONCLUSION: Our study revealed that over half of patients with acromegaly had SDB. Furthermore, SDB severity decreases with acromegaly treatment; however, this decrease does not change the indication for PAP therapy; therefore, PAP therapy should not be delayed in acromegalic SDB patients.

Disseminated scar sarcoidosis may predict pulmonary involvement in sarcoidosis.

Sarcoidosis is a chronic, inflammatory, multi-organ disease of unknown origin that is characterized by non-caseating granuloma formation in affected organs. Cutaneous involvement is reported in 25% of patients with sarcoidosis. Scar sarcoidosis is rare but is clinically specific for skin sarcoidosis. Systemic involvement is seen in most patients with scar sarcoidosis. We present a case of scar sarcoidosis in a 30-year-old male that developed infiltrated nodules on old scars, including on his penile shaft, which is rare, and that also had pulmonary involvement. Scar sarcoidosis should be considered in the differential diagnosis of changes in all scar areas and should be investigated for systemic involvement.

[The clinical value of autofluorescence bronchoscopy for precancerous lesions in operable primary lung cancer patients]. / Primer akciger karsinomu nedeniyle opere edilecek hastalarda otofloresan bronkoskopi ile prekanseröz lezyonlarin arastirilmasi.

INTRODUCTION: The aim of the present study is to show the role of autofluorescence bronchoscopy (AFB) compare with white light bronchoscopy (WLB) in detecting synchronous cancer and precancerous lesions in cases with operable primary lung cancer. MATERIALS AND METHODS: Fourty-nine patients were included in the study. WLB findings were grouped as group 1 normal, group 2 erithema or edema, group 3 nodular lesions or mucosal abnormality. AFB findings were grouped as group 1 normal, group 2 light brownish abnormal areas, group 3 brownish abnormal areas. Biopsies were obtained from group 2 and 3 patients. In 12 (24.5%) of the patients no areas were suspected and no biopsies were taken. RESULTS: Twenty-six (53%) of 49 patients did not show abnormal biopsy results in any of the specimens. One (2%) patient had metaplasia, 1 (2%) patient had dysplasia, 1 (2%) patient had in situ carcinoma. The diagnostic accuracy rates for the detection of synchronous cancer and precancerous lesions using WLB and AFB were as follows respectively: sensitivity 77.8% vs. 100%; specificity 37.5% vs. 3%; positive predictive value 21.9% vs. 24.3%; negative predictive value 88.2% vs. 100%. The relative sensitivity of AFB to WLB is 1.28. CONCLUSION: This study demonstrated that, AFB is an effective method in detecting synchronous cancer and precancerous lesions because of its low specificity it is more likely to be complementary to WLB.

[Relationship between symptoms of obstructive sleep apnea syndrome and traffic accidents in the city drivers]. / Sehir içi araç kullanan soförlerde obstrüktif uyku apne sendromu semptomlari ve trafik kazasi iliskisi.

INTRODUCTION: There is a high tendency for traffic accidents in patients with obstructive sleep apnea syndrome (OSAS). Thus it's recommended to investigate OSAS symptoms before certification of professional drivers. However, to what degree OSAS symptoms predict traffic accidents is not clear. We aimed to investigate the relationship between OSAS symptoms and traffic accidents. MATERIALS AND METHODS: Five hundred twenty bus drivers working at Istanbul Electricity, Tramway and Tunnel (IETT) general management were randomly selected. Berlin questionnaire was applied which included demographic data, accident ratios, total duration in profession, duration of working in a day and OSAS symptoms. Epworth sleepiness score (ESS) test was applied to assess day time slepiness. RESULTS: All drivers were male. Snoring were present in 324 (65.7%) of participants. Traffic accident history were present in 259 (49.7%) of drivers. Significant relationship was present between traffic accident and only daytime sleepiness among the OSAS symptoms. The mean of accident/year ratio of all participants were 0.092. Mean of ESS was 7.3 ± 3.2 for all participants. There is a positive correlation between ESS and accident/year ratio (r= 0.57, p= 0.012). CONCLUSION: Only daytime sleepiness among OSAS symptoms is related with traffic accident. The questioning of OSAS symptoms alone is inadequate to estimate traffic accident risk. Thus further consideration more than symptom questioning is needed at phase of authorization of professional drivers to detect OSAS.

[The frequency and properties of REM related obstructive sleep apnea among the patients with mild related obstructive sleep apnea]. / Hafif obstrüktif uyku apneli hastalarda REM ile iliskili obstrüktif uyku apne sikligi ve özellikleri.

INTRODUCTION: The question if REM related obstructive sleep apnea (OSA) is a specific clinical entity or if it is an early sign of severe sleep disordered breathing as there is high occurrence of REM OSA in mild and moderate cases, recently have attracted the investigators. In this study, we aimed to see the frequency of REM related OSA among patients with mild OSA; and also to evaluate relation between apnea and daytime sleepiness among REM related OSA patients. MATERIALS AND METHODS: One hundred thirty four patients with mild OSA [Apnea hipopnea index (AHI)= 5-15] among 1267 patients with polysomnography examination at sleep laboratory of Bezmialem University Hospital between 1st August 2010 and 29th February 2012 were retrospectively evaluated. Patients having REM AHI/non-REM AHI ≥ 2 and non-REM AHI < 15 are considered as REM related OSA. RESULTS: Eighty (59%) of 134 patients with mild OSA were considered as REM related OSA. When REM related OSA and non REM OSA are compared for age, gender, daytime sleepiness, body mass index, neck surround and aditional diseases; mean age of REM related OSA group was found only significantly lower. Number of AHI in REM was over 15 at 87.3% of REM related OSA group and over 30 at 39.3% of them. There was no relation between REM AHI and daytime sleepiness symptom (p= 0.81). CONCLUSION: We may consider the result of lower mean age in REM related OSA group as a supporting result for early sign of severe sleep disordered breathing. We consider to follow up this group of patients to answer the question about subject.

The effect of sleep apnea syndrome on the development of diabetic nephropathy in patients with type 2 diabetes.

AIMS: Type 2 diabetes mellitus and obstructive sleep apnea syndrome (OSAS) are serious comorbidities. Effects of OSAS on diabetic microvascular complications are ongoing research subjects. We evaluated the incidence of OSAS in Type 2 diabetes mellitus patients with nephropathy and with no renal involvement. METHODS: A total of 52 people with diabetes were enrolled in this study. Patients body mass indices were calculated and fasting glucose, glycosylated hemoglobin, urea, creatinine, total lipid profile, and urinary albumin excretion were evaluated. Full polysomnography was used to detect sleep disorders. RESULTS: Baseline characteristics and laboratory results of the patients were similar. Meeting criteria for OSAS was detected in 35 of the 54 patients (67.3%). 25 patients (48%) had mild, six patients (11.5%) had moderate, and four patients (7.7%) had severe sleep disorders. There was no significant relationship between respiratory obstructive parameters and microalbuminuria (R=0.91, p=0.362). Substantial correlation was detected between lower values of serum triglyceride levels and lower respiratory indices (R=0.299, p=0.031). CONCLUSIONS: In type 2 diabetes accompanying OSAS affects glucose regulation but its effect on nephropathy development is currently a subject of research.